Catastrophic Hemorrhage Research Articles

Tourniquets in the treatment of prehospital haemorrhage

Background: During recent conflicts in Iraq and Afghanistan, tourniquets were a useful tool in the management of non-compressible prehospital catastrophic haemorrhage. Recommendations for use within the civilian setting were then made. However, civilian research supporting this change in practice is limited. Aims: The aim of the research is to evaluate the utility of prehospital tourniquet application through description of the complications associated with use, as well as identification of mortality following prehospital application. Methods: A literature search was completed using PubMed and Embase for research studies on prehospital tourniquet use in extremity trauma. Study relevance was confirmed via their abstracts and final selection was made through reviewing the full publication. Data were extracted on mortality, complications, indication for use, effective application and application duration of tourniquet use. This was tabulated, and a descriptive analysis performed. Results: The research reported a mortality range of 3–14% with an associated complication rate of 2.1–32.4%. The effectiveness of prehospital application was in the 88.8–98.7% range, with tourniquet application durations of 48–103.2 minutes. Conclusions: The tourniquet should continue to be available to UK paramedics for the management of prehospital non-compressible catastrophic haemorrhage. Application is likely to provide a mortality benefit with limited morbidity and associated complications.

Catastrophic haemorrhage in military major trauma patients: a retrospective database analysis of haemostatic agents used on the battlefield

ObjectivesCatastrophic haemorrhage is a leading cause of morbidity and mortality in trauma, in both military and civilian settings. There are numerous studies looking at the effectiveness of different haemostatic agents...

Evans syndrome: clinical perspectives, biological insights and treatment modalities.

Evans syndrome (ES) is a rare and chronic autoimmune disease characterized by autoimmune hemolytic anemia and immune thrombocytopenic purpura with a positive direct anti-human globulin test. It is classified as primary and secondary, with the frequency in patients with autoimmune hemolytic anemia being 37%–73%. It predominates in children, mainly due to primary immunodeficiencies or autoimmune lymphoproliferative syndrome. ES during pregnancy is associated with high fetal morbidity, including severe hemolysis and intracranial bleeding with neurological sequelae and death. The clinical presentation can include fatigue, pallor, jaundice and mucosal bleeding, with remissions and exacerbations during the person’s lifetime, and acute manifestations as catastrophic bleeding and massive hemolysis. Recent molecular theories explaining the physiopathology of ES include deficiencies of CTLA-4, LRBA, TPP2 and a decreased CD4/CD8 ratio. As in other autoimmune cytopenias, there is no established evidence-based treatment and steroids are the first-line therapy, with intravenous immunoglobulin administered as a life-saving resource in cases of severe immune thrombocytopenic purpura manifestations. Second-line treatment for refractory ES includes rituximab, mofetil mycophenolate, cyclosporine, vincristine, azathioprine, sirolimus and thrombopoietin receptor agonists. In cases unresponsive to immunosuppressive agents, hematopoietic stem cell transplantation has been successful, although it is necessary to consider its potential serious adverse effects. In conclusion, ES is a disease with a heterogeneous course that remains challenging to patients and physicians, with prospective clinical trials needed to explore potential targeted therapy to achieve an improved long-term response or even a cure.

Cholecystocolonic Fistulous Catastrophe!

Cholecystocolonic fistula (CCF) is a rare complication of biliary disease with communication between the gallbladder and colon. Patients may present with symptoms similar to that seen in cholecystitis; however, diagnosis is often made intraoperatively and rarely with barium enemas. This gastrointestinal (GI) complication which is classified under biliary-enteric fistula comprises less than 0.2% of all biliary tract disease. We present a rare case of CCF complicated by a catastrophic cystic artery hemorrhage presenting as a lower GI bleed. An 87 year-old male with a past medical history of abdominal aortic aneurysm status post graft presented with syncope preceded by multiple episodes of bloody diarrhea. He had no other GI complaints. On admission, his hemoglobin was 4.5 g/dL and hemodynamically unstable, requiring transfer to the ICU where vasopressors and a massive transfusion protocol were initiated. CT angiography of the abdomen was performed to evaluate for possible aortoenteric fistula. This revealed gangrenous cholecystitis and blood in the hepatic flexure of the large intestine. A colonoscopy was performed revealing blood protruding from a 15 mm fistulous opening at the hepatic flexure. Both epinephrine was injected and one hemostatic clip was placed without achievement of hemostasis. Upon further radiographic review, it was revealed that he had a CCF with a hemorrhagic cystic artery. Given this, he was taken to interventional radiology where they appreciated bleeding from the cystic artery into the CCF at the location seen on colonoscopy. Cystic artery embolization was done with hemostasis and stabilization of the patient's hemoglobin. He received 28 units of packed red blood cells during his hospitalization and was discharged after surgical consultation. CCFs are rare occurrences in the field of gastroenterology. Studies have shown that the typical picture of CCF consists of a triad of symptoms-diarrhea, right hypocondrium pain, and cholangitis. Etiologies can include cholecystitis, malignancy, and cholelithiasis with a track being formed along the track of the gallstones as they erode through the inflamed gallbladder into adjacent bowel. Furthermore, CCF can in unique cases be extensively complicated by mass GI hemorrhage as reported here and treatment can include surgical and endoscopic options. Overall, CCF is a rare phenomenon, but should be included in a differential diagnosis for diarrhea and the triad of symptoms mentioned earlier.

Colonic Varices: An Under-Recognized but Potentially Deadly Complication of Cirrhosis

While esophageal varices are well-established sequela of portal hypertension, colonic varices are rare, with less than 100 published cases. Due to the paucity of data, there are no established clinical guidelines for treatment. We report a case of colonic varices associated with liver cirrhosis in a gentleman presenting with hematochezia. A 48 year old male with alcoholic liver cirrhosis and esophageal varices presented with profuse rectal bleeding resulting in shock. He was intubated and started on vasopressors for hemodynamic instability. Hemoglobin was 6.4 g/dL. The massive transfusion protocol was initiated for intractable bleeding. Urgent upper endoscopy revealed no active source of bleeding. Interventional Radiology was consulted for emergent embolization however his mesenteric angiogram showed a nonbleeding right colonic varix. Surgical intervention was deferred due to hemodynamic instability. Due to ongoing bleeding after his mesenteric angiogram, he underwent a CT angiogram which revealed bleeding in the cecum from colonic varices. Transjugular intrahepatic portosystemic shunt (TIPS) was performed for portal decompression and the varices were embolized controlling the bleeding transiently. He developed disseminated intravascular coagulation 7 hours later leading to recurrence of bleeding. The course was further complicated by acute respiratory distress syndrome. He eventually expired from his complications. Colonic varices can present with a variety of manifestations from abdominal pain to catastrophic gastrointestinal bleeding, as in our patient. The most accurate diagnostic modality is CT or mesenteric angiography, with varices identified on the venous phase. Unfortunately, due to scarcity of cases, there are no treatment guidelines. In cases of portal hypertension and severe bleeding, therapy targeted towards portal decompression can be effective, as seen in esophageal varices. Although our patient eventually passed away from complications, TIPS proved to be an effective temporizing measure to manage hematochezia. In rare cases of massively bleeding colonic varices, prompt diagnosis and treatment aimed to reduce portal hypertension is imperative in decreasing mortality.2017_A Figure 1. Varices seen to the right colon/hepatic flexure.2017_B Figure 2. Enlarged venous collateral (colonic varices) originating from the distal portal vein.2017_C Figure 3. TIPS extending from the right portal vein into the right hepatic vein.

Strip of the Month: A Catastrophic Fetal Intracranial Hemorrhage

Strip of the Month: A Catastrophic Fetal Intracranial Hemorrhage

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P62. Application of laparoscopic lumbar discectomy and artificial disc replacement: at least two years of follow-up

BACKGROUND CONTEXT Symptomatic degenerative disc disease is the major cause of low back pain with lumbar segmental instability. Artificial disc replacement (ADR) has increased in popularity as an alternative treatment for lumbar disc herniation. However, the traditional approach to spinal surgery carries the risk of catastrophic bleeding from injury to major vessels, as well as iatrogenic injury to the viscera and associated structures. Therefore, laparoscopic lumbar discectomy and ADR may represent a useful alternative. PURPOSE The current study aimed to assess the safety and efficacy of ADR using a laparoscopic technique for lumbar disc herniation. STUDY DESIGN/SETTING This prospective observational study included 22 patients who were diagnosed with symptomatic degenerative disc disease treated via ADR with a laparoscopic technique. PATIENT SAMPLE Twenty-two patients (8 males and 14 females) who were diagnosed with symptomatic degenerative disc disease were included in this study. Seven cases involved the L4/5 level, and 15 cases involved the L5/S1 level. All patients were ineffective after at least 6 months of conservative treatments; all patients were informed of the surgery before the operation and provided consent. OUTCOME MEASURES Three-dimensional computed tomographic angiography (3D-CTA) of the iliac great blood vessels was completed before the surgery. All surgical procedures were performed under a laparoscope. All patients were followed up. METHODS Twenty-two patients (8 males and 14 females) who were diagnosed with symptomatic degenerative disc disease were included in this study. Seven cases involved the L4/5 level, and 15 cases involved the L5/S1 level. All patients were ineffective after at least 6 months of conservative treatments; all patients were informed of the surgery before the operation and provided consent. Three-dimensional computed tomographic angiography (3D-CTA) of the iliac great blood vessels was completed before the surgery. All surgical procedures were performed under a laparoscope. All patients were followed up. RESULTS All surgeries were successfully completed. The average operation time was 120 minutes (range 110–150 minutes), and the average hemorrhage was 145 mL (range 80–360 mL). All cases underwent X-ray imaging at 3days, 3 months, 6 months, 1 year, and the final postoperative follow-up. The outcome indicated that there was no mobilization, displacement, or subsidence in all patients with the exception of one case with prosthesis migration. The follow-up time was 43.8 months (range 24–64 months). The mean visual analog scale (VAS) and Oswestry scores were decreased postoperatively. The mean improvement rate of the VAS score was 73.5%. CONCLUSIONS Lumbar ADR using a laparoscope represents a novel, minimally invasive treatment for symptomatic degenerative disc disease and severe lumbar discogenic pain.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P134. Application of laparoscopic lumbar discectomy and anterior lumbar interbody fusion: at least six years of follow-up

BACKGROUND CONTEXT Symptomatic degenerative disc disease is the major cause of low back pain with lumbar segmental instability. Anterior discectomy and interbody fusion has increased in popularity as an alternative treatment for lumbar disc herniation. However, the traditional approach to spinal surgery carries the risk of catastrophic bleeding from injury to major vessels, as well as iatrogenic injury to the viscera and associated structures. Therefore, laparoscopic lumbar discectomy and interbody fusion may represent a useful alternative. PURPOSE The current study aimed to assess the mid-term safety and efficacy of lumbar discectomy and anterior lumbar interbody fusion (ALIF) using a laparoscopic technique for lumbar disc herniation. STUDY DESIGN/SETTING This prospective observational study included 32 patients who were diagnosed with symptomatic degenerative disc disease treated via lumbar discectomy and ALIF with a laparoscopic technique. PATIENT SAMPLE Thirty-two patients (12 males and 20 females) who were diagnosed with symptomatic degenerative disc disease were included in this study. Four cases involved the L4/5 level, and 28 cases involved the L5/S1 level. All patients were ineffective after at least 6 months of conservative treatments; all patients were informed of the surgery before the operation and provided consent. OUTCOME MEASURES All patients were followed up for more than 6years, X-ray and CT were reviewed regularly to evaluate the height change of intervertebral space and the fusion of bone graft. The clinical effects of preoperative, postoperative and follow-up were evaluated by VAS score, and the complications of laparoscopic surgery were observed. METHODS Thirty-two patients (12 males and 20 females) who were diagnosed with symptomatic degenerative disc disease were included in this study. Four cases involved the L4/5 level, and 28 cases involved the L5/S1 level. All patients were ineffective after at least 6 months of conservative treatments; all patients were informed of the surgery before the operation and provided consent. Three-dimensional computed tomographic angiography (3D-CTA) of the iliac great blood vessels was completed before the surgery. All surgical procedures were performed under a laparoscope. All patients were followed up for more than 6years, X-ray and CT were reviewed regularly to evaluate the height change of intervertebral space and the fusion of bone graft. The clinical effects of preoperative, postoperative and follow-up were evaluated by VAS score, and the complications of laparoscopic surgery were observed. RESULTS All surgeries were successfully completed. All cases were followed up for more than 6years, the average follow-up time was 9years (range 6–12 years). All cases got bone fusion, the average time was 4.5 months (range 3–12 months). The mean VAS were decreased postoperatively, The VAS score of low back pain for preoperative, postoperative (1 week) and final follow-up was 5.8±1.1, 1.8±0.7, 0.9±0.7, the change were statistically significant (p .05). The outcome indicated that there was no mobilization, displacement or intestinal adhesion in all patients in the mid-term follow-up. CONCLUSIONS Laparoscopic lumbar discectomy and ALIF is an effective treatment for severe degenerative lumbosacral diseases

Common and Uncommon Imaging Presentations of Ectopic Pregnancy

Ectopic pregnancy most commonly occurs in a fallopian tube (∼95%1) (Figure 1). Major risk factors for ectopic pregnancy include a history of pelvic inflammatory disease or previous tubal surgery. Additional risk factors include smoking, assisted reproductive technology, and the use of an intrauterine device.2 Ectopic pregnancies located outside the fallopian tube have a poorer prognosis, as they have more blood supply, grow larger, and have an elevated risk of catastrophic hemorrhage if ruptured. The clinical presentation of pelvic pain, elevated β-human chorionic gonadotropin, and vaginal bleeding is similar, regardless of the location of an ectopic pregnancy; thus, imaging plays a crucial role in directing management. Early diagnosis by imaging has played a key role in reducing maternal mortality and allowing patients to pursue more conservative management options to reduce morbidity and preserve future fertility. However, ruptured ectopic pregnancy still remains the leading cause of maternal death in the first trimester.3 Uncommon locations of ectopic pregnancy often are missed or incorrectly diagnosed at initial imaging, resulting in poor outcomes.

Endovascular Treatment of Pulmonary Arteriovenous Malformations: How We Do It

Pulmonary arteriovenous malformation (PAVM) is a rare disease disproportionally affecting patients with hereditary hemorrhagic telangiectasia and may be associated with other pulmonary or infectious etiologies. Respiratory symptoms are the most common, including dyspnea, hypoxemia, and hemoptysis. Due to the impairment of normal pulmonary filtration function, patients with PAVM are at risk for embolic events, ranging from ischemic strokes to brain abscesses. More importantly, PAVM can enlarge over time or with physiological changes, which may lead to catastrophic hemorrhages and increased embolization risks. From imaging perspective, echocardiography with contrast bubbles and computed tomography can both be used to diagnose PAVMs with high sensitivity and specificity. Treatment modalities have evolved from invasive surgeries to transluminal catheter-based interventions. In recent decades, the evolution of interventional techniques and equipment has resulted in a high technical success rate for the treatment of PAVMs. Here, we present the interventional PAVM treatment protocol at our institution.

Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism.

Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality in the United States. PE associated with right ventricular strain, termed submassive or intermediate-risk PE, is associated with an increased rate of clinical deterioration and short-term mortality. Trials have demonstrated systemic thrombolytics may improve patient outcomes, but they carry a risk of major hemorrhage. Catheter-directed thrombolysis (CDT) may offer similar efficacy to and a lower risk of catastrophic hemorrhage than systemic thrombolysis. Three prospective trials have evaluated CDT for submassive PE; ULTIMA, SEATTLE II, and PERFECT. These trials provide evidence that CDT may improve radiographic efficacy endpoints in submassive PE with acceptable rates of major hemorrhage. However, the lack of clinical endpoints, long-term follow-up, and adequate sample size limit their generalizability. Future trials should be adequately powered and controlled so that the short- and long-term effectiveness and safety of CDT can be definitively determined.

Characteristics of fibrinolytic disorders in acute promyelocytic leukemia

ABSTRACTObjectives: Catastrophic hemorrhage remains the main cause of acute promyelocytic leukemia (APL) treatment failure. This study was aimed to study the pathogenesis of coagulopathy in patients with APL.Methods: Multiple procoagulant and profibrinolytic parameters in plasma and peripheral leukocytes from 24 patients with newly diagnosed APL accompanied by coagulopathy before and after arsenic trioxide (ATO) treatment were evaluated.Results: Prior to the treatment, the patients had elevated D-dimer and decreased fibrinogen levels. Plasma urokinase-type plasminogen activator receptor (uPAR) and plasmin–ɑ2 antiplasmin complexes (PAP) levels, plasmin (Pn) activity, and cell surface levels of urokinase-type plasminogen activator (uPA) and tissue-type plasminogen activator (tPA) were significantly higher; plasma plasminogen activator inhibitor-1 (PAI-1) levels and plasminogen (Pg) activity were significantly decreased; plasma plasminogen activator (PA) activity, uPA and tPA levels; and cell surface levels of uPAR and annexin II were not significantly different from levels in the control group. During ATO treatment, both patients’ plasma PA activity and uPAR on leukocytes gradually increased, annexin II on leukocytes increased initially and decreased afterwards, and tPA and uPA on leukocytes remained consistently higher in the patients than in the controls. Other parameters gradually tended toward normal values.Conclusions: In APL, activated coagulation system activated fibrinolytic system, and increased uPAR levels could contribute to the hyperfibrinolysis. Annexin II might not be involved in the coagulopathy.

Physiology and Role of Intraocular Pressure in Contemporary Anesthesia.

More than 26 million Americans suffer with cataracts, and with 3.6 million cataract extractions performed annually in the United States, it is the most common surgical procedure. The integrity of the delicate structures of the eye that mediate vision is dependent on the intraocular pressure (IOP). Yet, IOP acts to compress the vessels within the globe-akin to a Starling resistor-and is a key component that determines the ocular perfusion pressure, defined as the difference between arterial pressure and IOP. The retina is one of the most metabolically active tissues in the body, and its functional integrity is dependent on an adequate blood supply, with retinal function linearly related to the ocular perfusion pressure. Retinal cell death has been demonstrated at low perfusion pressures (below 50 mm Hg). Modern ophthalmic surgery involves globe irrigation, manipulation, and instrumentation, resulting in dynamic pressure fluxes within the eye. Marked elevations of IOP (up to 4-5 times the normal value) with consequent borderline retinal and optic disk perfusion pressures occur for prolonged periods during many ophthalmic procedures. General surgeries, including laparoscopic, spinal, and cardiac procedures, especially, with their demand for steep Trendelenburg or prolonged prone positioning and/or hypotensive anesthesia, can induce IOP changes and ocular perfusion imbalance. These rapid fluctuations in IOP, and so in perfusion, play a role in the pathogenesis of the visual field defects and associated ocular morbidity that frequently complicate otherwise uneventful surgeries. The exact etiology of such outcomes is multifactorial, but ocular hypoperfusion plays a significant and frequently avoidable role. Those with preexisting compromised ocular blood flow are especially vulnerable to intraoperative ischemia, including those with hypertension, diabetes, atherosclerosis, or glaucoma. However, overly aggressive management of arterial pressure and IOP may not be possible given a patient's comorbidity status, and it potentially exposes the patient to risk of catastrophic choroidal hemorrhage. Anesthetic management significantly influences the pressure changes in the eye throughout the perioperative period. Strategies to safeguard retinal perfusion, reduce the ischemic risk, and minimize the potential for expulsive bleeding must be central to the anesthetic techniques selected. This review outlines: important physiological principles; ophthalmic and general procedures most likely to develop damaging IOP levels and their causative factors; the effect of anesthetic agents and techniques on IOP; recent scientific evidence highlighting the significance of perfusion changes during surgery; and key aspects of postoperative visual loss and management approaches for high-risk patients presenting for surgery.

(22) Use of ECMO in Pediatric Multi-trauma Patient with Severe Pulmonary Airleak

INTRODUCTION: Extracorporeal Membrane Oxygenation (ECMO) for Acute Respiratory Distress Syndrome after trauma is controversial. Most lung injury after trauma resolves with conventional ventilation. Venovenous ECMO is utilized for refractory respiratory failure in non-surgical patients; its use in trauma patients is controversial due to concerns of catastrophic bleeding, the presence of intracranial pathology, acute coagulopathy and the potential for multiple surgical interventions. CASE REPORT: Patient is an 11-year-old male who was ejected through the sunroof during a motor vehicle collision (MVC). EMS intubated him at the scene. He had bilateral chest …

Transient Focal Neurological Episodes with Subsequent Catastrophic Intracerebral Hemorrhage Due To Cortical Superficial Siderosis and Amyloid Angiopathy (P1.233)

Transient Focal Neurological Episodes with Subsequent Catastrophic Intracerebral Hemorrhage Due To Cortical Superficial Siderosis and Amyloid Angiopathy (P1.233)

Bleeding in cancer patients and its treatment: a review.

Bleeding is a common problem in cancer patients, related to local tumor invasion, tumor angiogenesis, systemic effects of the cancer, or anti-cancer treatments. Existing bleeds can also be exacerbated by medications such as bevacizumab, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants. Patients may develop acute catastrophic bleeding, episodic major bleeding, or low-volume oozing. Bleeding may present as bruising, petechiae, epistaxis, hemoptysis, hematemesis, hematochezia, melena, hematuria, or vaginal bleeding. Therapeutic intervention for bleeding should start by establishing goals of care, and treatment choice should be guided by life expectancy and quality of life. Careful thought should be given to discontinuation of medications and reversal of anticoagulation. Interventions to stop or slow bleeding may include systemic agents or transfusion of blood products. Noninvasive local treatment options include applied pressure, dressings, packing, and radiation therapy. Invasive local treatments include percutaneous embolization, endoscopic procedures, and surgical treatment.

Snapshot of trauma laparotomy deaths in Queensland

Trauma remains the most frequent cause of death for patients under 35 years of age. Head injury and catastrophic haemorrhage account for the majority of early deaths. A trauma laparotomy is often necessary to arrest haemorrhage. All patients who died in Queensland hospitals between 2011 and 2016 having had a trauma laparotomy were identified from the Queensland Audit of Surgical Mortality. About 69.0% of the 84 deaths were male with a median age of 47.6 years. About 64.3% of deaths occurred within the first 2 days following trauma. Mechanism of injury was typically road traffic accident (77.4%). Sixteen patients underwent a non-therapeutic laparotomy. Following peer-review, different management was recommended for only three patients. This group of patients who died in the setting of a trauma laparotomy received high quality trauma care. Ongoing education is needed as some non-therapeutic laparotomies may be avoidable.

Soluble FLT-1 rules placental destiny

IntroductionPlacenta previa is an abnormality in which the placenta covers the internal uterine os, and it can cause serious morbidity and mortality in both mother and fetus due to catastrophic hemorrhage. Some pregnant women recover from placenta previa due to a phenomenon called “migration.” However, the mechanism of “migration” of the placenta has not been elucidated. MethodsHuman placentas were collected from patients with placenta previa and those with no abnormal placentation (control). A microarray analysis was performed to detect the genes up- or down-regulated only in the caudal part in the previa group. Specific mRNA expression was evaluated using real-time quantitative reverse transcription PCR (qRT-PCR). Unilateral uterine artery ablation of 8.5 dpc mice was performed to reproduce the reduction of placental blood supply, and weights of the placentas and fetuses were evaluated in 18.5 dpc. Specific mRNA expression was also evaluated in mice placentas. ResultsAccording to the result of the microarray analysis, we focused on soluble fms-like tyrosine kinase-1 (sFLT-1) and hypoxia-inducible factor-1 (HIF-1) alpha. The sFLT-1 expression level is locally high in the caudal part of the human placenta in patients with placenta previa. In mice experiments, the weights of the placentas and fetuses were significantly smaller in the ablation side than those in the control side, and the sFlt-1 expression level was significantly higher in the ablation side than in the control side. DiscussionOur study suggests that “migration” of the placenta is derived from placental degeneration at the caudal part of the placenta, and sFlt-1 plays a role in this placental degeneration.

Bleeding in cancer patients and its treatment: a review

Bleeding is a common problem in cancer patients, related to local tumor invasion, tumor angiogenesis, systemic effects of the cancer, or anti-cancer treatments. Existing bleeds can also be exacerbated by medications such as bevacizumab, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants. Patients may develop acute catastrophic bleeding, episodic major bleeding, or low-volume oozing. Bleeding may present as bruising, petechiae, epistaxis, hemoptysis, hematemesis, hematochezia, melena, hematuria, or vaginal bleeding. Therapeutic intervention for bleeding should start by establishing goals of care, and treatment choice should be guided by life expectancy and quality of life. Careful thought should be given to discontinuation of medications and reversal of anticoagulation. Interventions to stop or slow bleeding may include systemic agents or transfusion of blood products. Noninvasive local treatment options include applied pressure, dressings, packing, and radiation therapy. Invasive local treatments include percutaneous embolization, endoscopic procedures, and surgical treatment.

Review of Peripartum Hysterectomy Rates at a Tertiary Australian Hospital

(Aust N Z J Obstet Gynaecol. 2016;56(6):614–618) Peripartum hysterectomy is a surgical procedure performed in the event of catastrophic postpartum hemorrhage uncontrolled by other medical and surgical therapies. In the last 3 decades, the major indication for peripartum hysterectomy has been abnormal placentation, including placenta previa, accreta, increta, or percreta. A large body of evidence suggests that a history of cesarean section (CS) is significantly associated with abnormal placentation, which is especially troubling for the antenatal population of Queensland (QLD), Australia, as the CS rate is currently higher than the national average.